Protesters against President Barack Obama's 2010 healthcare overhaul hold signs outside the Supreme Court in Washington. A sharply divided Supreme Court on Thursday upheld the centerpiece of Obama's signature healthcare overhaul law that requires that most Americans get insurance by 2014 or pay a financial penalty. (REUTERS/Jason Reed)

Supreme Court says yes to mandate, no on Medicaid

By ROBERT BARNESThe Washington Post

Health insurance in NH

The Supreme Court upheld the Patient Protection and Affordable Care Act but opened the door to a renewed debate in state participation in an expansion of the federal-state Medicaid program for the poor. Here are some key New Hampshire figures:

Medicaid enrollees: 129,000 in fiscal year 2009; 165,000 in fiscal year 2010.

Uninsured residents: 134,000 estimated, about 10 percent of the population.

Privately insured residents: 665,000

Medicare enrollees: 220,000 (about 17,000 are dual eligibles for both Medicare and Medicaid).

Veterans (Tri-Care): 40,000

Sources: New Hampshire Fiscal Policy Institute Issue Brief; Dhhs Office of Medicaid Business and Policy , U.S. Census data. (Total figures may add up to more than the state's population because of dual coverage.)

Chief Justice John G. Roberts Jr. Thursday joined the liberal wing of the Supreme Court to save the heart of President Obama's landmark health-care law, agreeing that the requirement for nearly all Americans to secure health insurance is permissible under Congress's taxing authority.

Even as it upheld that central component of the Patient Protection and Affordable Care Act, however, the court modified another key provision of the law, ruling that the federal government cannot withdraw existing Medicaid funding from states that decide not to participate in a broad expansion of Medicaid eligibility.

The court's historic compromise, which will affect the health-care choices of millions of Americans, amounts to a major victory for the White House less than five months before the November elections, although the Medicaid decision sets new limits on the power of the national government.

President Obama welcomed the ruling, which he called ';a victory for people all over this country whose lives will be more secure.';

He said the decision would allow the health-care law to offer millions of currently uninsured Americans ';an array of quality, affordable health-insurance plans to choose from'; starting in 2014.

';Today the Supreme Court also upheld the principle that people who can afford health insurance should take the responsibility to buy health insurance,'; Obama said in televised speech at the White House. He said he knew that this individual mandate ';wouldn't be politically popular'; and that the debate over the law ';has been divisive.'; But he said the law was ';good for the country'; and ';good for the American people.';

A scathing dissent

Illustrating the divided nature of the ruling, Justice Anthony M. Kennedy, representing the court's most consistent conservatives, read a scathing dissent, while Justice Ruth Bader Ginsburg, representing the liberals, issued a separate opinion supporting Roberts but differing with him on key aspects of the case.

Joined by Justices Antonin Scalia, Clarence Thomas and Samuel A. Alito Jr., Kennedy called the majority's decision a ';vast judicial overreaching'; that ';creates a debilitated, inoperable version of health care regulation that Congress did not enact and the public does not expect.';

The Medicaid ruling, Kennedy said, leaves state governments in a difficult position: ';States must choose between expanding Medicaid or paying huge tax sums ... for the sole benefit of expanding Medicaid in other states.';

The high court rejected the argument, advanced by the Obama administration, that the individual mandate was constitutional under the commerce clause of the Constitution. But Roberts joined the court's four liberal justices — Ginsburg, Sonia Sotomayor, Stephen G. Breyer and Elena Kagan — in ruling that a penalty for refusing to buy health insurance amounts to a tax and thus is permitted. Ginsburg favored going further and allowing the mandate under the commerce clause.

Romney's vow to repeal

Passage of the legislation by the Democratic-controlled Congress in 2010 capped decades of efforts to implement a national program of health care. The act is supposed to eventually extend health-care coverage to more than 30 million Americans who currently lack it.

';No longer will Americans be a heart attack or a car crash away from bankruptcy,'; Senate Majority Leader Harry M. Reid, D-Nev., said in a speech on the Senate floor Thursday after the ruling. ';No longer will Americans live in fear of losing their health insurance because they lose their job.';

Republicans in Congress and GOP presidential challenger Mitt Romney have vowed to try to repeal the measure.

';What the court did not do on its last day in session, I will do on my first day as President,'; Romney said. ';And that is, I will act to repeal Obamacare.';

Four questions

The court reviewed four questions: whether it was within Congress's constitutional powers to impose the individual mandate to purchase health insurance; whether all or any additional parts of the law must be struck down if the mandate is rejected; whether an expansion of Medicaid was unduly coercive on the states and whether all of those questions can even be reviewed before the mandate takes effect.

The individual mandate, known technically as the ';minimum coverage'; provision, was considered a crucial part of the overall health-care legislation because striking it down would have jeopardized the ability of insurers to comply with other, more popular elements of the law without drastically raising premiums.

Under those other provisions, for example, insurers can no longer limit or deny benefits to children because of a preexisting condition, and young adults up to age 26 are eligible for insurance coverage under their parents' plans.

Individual mandate

During oral arguments in March, conservative justices indicated they were skeptical about the individual mandate, the provision in the 2,700-page health-care law that requires nearly all Americans to obtain health insurance by 2014 or pay a financial penalty.

Arguing the case for the Obama administration, Solicitor General Donald B. Verrilli Jr. defended the law as a constitutional exercise of congressional power under the charter's commerce clause to regulate interstate commerce. He said lawmakers were regulating health insurance to deal with the problem of millions of people who lack coverage and therefore shift costs to the insured when they cannot pay for their medical care.

Paul D. Clement, representing Florida and 25 other states objecting to the health-care law, argued that Congress exceeded its power in passing the law, which he said compels people to buy a product.